Background: Recent trials have demonstrated improved outcomes with endovascular therapy for ischemic stroke due to large vessel occlusion compared with alteplase. We examined the effects on disability, quality of life, survival and acute care cost in the EXTEND-IA trial.
Methods: Patients receiving alteplase within 4.5h of onset with major vessel occlusion and CT perfusion evidence of salvageable brain were randomized to endovascular thrombectomy after alteplase vs alteplase alone. Expected survival for each individual patient was modeled using age, gender and 3 month modified Rankin Scale (mRS). Utility scores were applied to estimate Disability/Quality-adjusted life years (DALY/QALY) saved. Cost of procedure and inpatient care within the first 3 months was calculated.
Results: There were 70 patients, 35 in each arm, mean age 69, median NIHSS 15. The median disability-weighted utility score at 3 months based on the observed mRS increased from 0.65 (IQR 0-0.91) in alteplase only to 0.91 (IQR 0.65-1) in the endovascular group (unadjusted p=0.005, adjusted for age and baseline NIHSS p=0.02). Modelled life expectancy was greater in the endovascular versus alteplase-only group (median 12.6 vs 7.4 years, p=0.048 unadjusted; HR 0.59 CI95 0.35-0.99, p=0.046 adjusted for age and baseline NIHSS). Applying utility scores, endovascular thrombectomy reduced lifetime DALY lost, median 5.5 (IQR 3.2-8.7) vs 8.9 (IQR 4.7-13.8), p=0.02 (non-discounted, non-age-weighted, with similar results regardless of age-weighting and discounting) and increased QALY gained, median 7.5 (IQR 2.7-10.2) vs 4.0 (IQR 0.3-6.9), p=0.03, (discounted, with similar results undiscounted). Endovascular patients spent less time in hospital (median 5 versus 8 days, p=0.04) and rehabilitation (median 0 versus 27 days, p=0.03) with reduced cost of inpatient care in the first 3 months (median US$12,188 versus US$26,112, p=0.009), saving US$2,417/patient after US$11,507 transport and thrombectomy procedural costs.
Conclusions: In ischemic stroke patients with large vessel occlusion and salvageable tissue on CT-perfusion, thrombectomy reduced costs and increased expected long term survival with reduced disability and improved quality of life.